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Home My WebLink AboutSUE TAWN ESTATE #2 BLK 1 LT 11A Municipality of Anchorage Page I of DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Permit Number: ~ f~. OtSG PID Number: Name: ~.~ AM¢ ~1~¢ ~ Wastewater System: ~ New D Upgrade ~d,~,~ ,~,~.~ ABSORPTION FIELD Phone: ~~J'~ ~ ~No, of Bedrooms:~ ~DeepTrench ~ Shallow Trench DBed ~Mound DOther Total Depth from original grade: LEGAL DESCRIPTION SoilRating: i~ '~ GPD/Sq. Ft. ~ ~ Lot: Block: Subdiv~ion: .~ 3epth to pipe bosom from original grade: Gravel depth beneath pipe Township:~Il Range: ~Il Section: ~ Fill added aboveia original~ j,~lgrade: Ft. Gravel length: ~.~ Ft. Number of lines: I Distan~ea lines: WELL: ~ New ~ Upgrade Gravelwidth: 2~¢l Ft. ~ Ft. Classification (Private, A,B,C): Total Depth: Cased TO: Total absorption area: Pipe material: ~¢~ Driller: Date Drilled: StaticWater Level: Installer: Date installed: ' TANK Yield: I~ GPM ~. ~. Ft. 3 Ft. SEPARATION DISTANCES ~s~,~i~ ~ Holding ~ S.T.E.P. TO Septic Absorption Lift Holding Public/P~ivate Manufacturer: Capscity in gallons: Erom Tank Field Station Tank Sewer La.es ~CI~ A~ ~ Number of Compa~ments: Wel~ J~C i.~ ~oot+ ~ ~ ~i~ Material: ~.~E~ Sudace W~t~r ,~+ ~o~t ~ ~ .__ LIFT STATION Lot ~, }2t Size in ga,,ons: I Manufacturer: Line ~ ~ [ ~ ~ "Pump on" level at:~ "Pum~" ' : J High water alarm at: Foundation I Cu~ainDrain ~ oi~i ~ ~ ~ ~ . Pu~Electrical Inspections pedormed~ by: Remarks: BENCH MARK Location and Description: ~O J~ ~ il ~ 1~ Assumed Elevation: Y~ 7034 ERgle River gaap Read, No. ~es: 1st ' Department of Healthand Human e~ices approval ,,..,~- Reviewed and approved by:~ ~ 72-013 (Rev. 9/91) MOA 25 SW960156 2 2 Permit No. Page of Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report LOT 11, BLOCK 1, SUE TAWN EASTATES //2 051-501-55 Legal Description: PID No.: *"'¢~7 FCO 4.0' 22.0' NEW TRENC ST1 45.0' 48.0' I DBL2 52.0' 53.5' I ~o MT1 68.5' 66.5' cp2 - 85~ STt T~ ~91.8' / FINAl GRADE~ 72-013 A (Rev. 9/91) MOA 25 000000000000 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 PAGE 1 OF ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT PERMIT NUMBER:SW960156 DESIGN ENGINEER:S & S ENGINEERING OWNER NAME:MAUS, JODT AND EILEEN OWNER ADDRESS:P.O. BOX 672235 CHUGIAK, AK 99567 DATE ISSUED: 6/26/96 EXPIRATION DATE: 6/26/97 PARCEL ID:05150133 LEGAL DESCRIPTION: SUETAWI~ ESTATE #2 BLK 1 LT 11 LOT SIZE: 58546 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 THIS PERMIT IS FOR THE CONSTRUCTION OF: DISPOSAL FIELD /SEPTIC TANK / WELL SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: 1. THE ATTACHED APPROVED DESIGN. 2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS 15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (iSAACS0) . 3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4744 ( 24 HOURS ) (NOT REQUIRED FOR WELL ONLY PERMIT) 4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER: A. OPENED AND CLOSED ON THE SAME DAY E. COVERED, SEALED AND HEATED TO PREVENT FREEZING 5. THE FOLLOWING SPECIAL PROVISIONS. 1 SPECIAL PROVISIONS: THE EXISTING WELL IS TO BE REDRILLED AND THE WELL LOG MUST PROVIDED AFTER THE WELL ~ COMPLETED. RECEIVED BY: ,.~ . ~'-'~';~--'-- DATE: 1:' = 60' SCALE O / / / / / SITE PLAN DESIGN -< 0 0 [-,.~:~ zo ~ c: ~q L--z-j z ~. :::u 0 1," = 50' ? / / SITE PLAN DETAIL PERFORMED FOR: LEGAL DESCRIPTION: 1 2 3 4 5 7 8 9- t0- 14- 17- 20- COMMENTS Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST (E ~.1~ L & ROBERT C. COWAN ~¢~ ~ CE 8~'01 ,~- DATE PERFORM b.~,,~ ~ ~' ~'~' '~ Township, Range, Section: - ' ;%' ' '~' ;~' ~ SLOPE SITE PLAN ENCOUNTERED? s DEPTH?IF YES. AT WHAT ~/~ Depth 10 Wale~.cADer~-- Menit0 inD'? ~ Dale:"l?- ~-~/ Reda ~31g- Da re~'~- Net Depth to Net Time Time Water Drop PERCOLATION RATE ~- tminutes/inch) PERC HOLE DIAMETER (=, R TEST RUN BETWEEN ~ FT AND "7 FT PERFORMED BY: S & $ ENGINEERING j . . . CERTIFY THAT THIS TEST WAS PERFORMED IN 17034 Eagle Ri,er Loop Road No. 204 ~//~/9(.? ACCORDANCE WIT~(~j~ fij~,c~e~J~ AJ~j~LI~L GUIDELINES IN EFFECT ON THIS DATE. DATE: 72-008 (Rev. 4/85) ROBERT C. COWAN, P.E. ROBERTA. SHAFER, P.E. June 7, 1996 ENGINEERING STUDIES AND REPORTS WELL INSPECTION & FLOWTEST ROAD DESIGN SOILTEST PERCOLATION TEST STRUCTURAL& MECHANICAL INSPECTIONS MUNICIPALITY OF ANCHORAGE Department of Health and Human Services P.O. Box 196650 Anchorage, AK. 99519 REFERENCE: Lot 11, Block 1, Sue Tawn Estates S/D ~2 CIVIL ENGINEERS (907) 694-2979 FAX (907) 694-1211 Request you issue a permit to install a septic serve the proposed three bedroom house on the property. system to referenced A test hole was excavated and percolation test performed. The approximate location of the test hole is located on the attached site plan. At the time of excavation no water was encountered in the test hole. The monitoring tube within the test hole has been checked and found to be dry. This property has enough area for a future septic upgrade which can be seen on the attached site plan. We do not anticipate any adverse effects on neighboring wells, septic systems or drainage patterns by the installation of the proposed septic system. If you require additional information, please contact us. Sincerely, Robert C. Cowan, P.E. RCC/gk Enclosure 17034 NORTH EAGLE RIVER LOOP · SUITE 204 · EAGLE RIVER, ALASKA 99577 SEWER&WATER INSPECTION ENGTNEERINGSTUD]ES ANO REPORTS WELL INSPECTION & FLOW TEST SITE PLANS ROADDESIGN SOILTEST PERCOLATION TEST S~RUCTURAL& MECHANICAL INSPECTIONS ON-SITE WASTEWATER DISPOSAL SYSTEM and MATERIAL SPECIFICATIONS ROBERTC. COWAN, EE. ROBERTA. SHAFER, RE. CIVIL ENGINEERS (907) 694~2979 FAX (907) 694-1211 REFERENCE: Lot 11, Block 1, Sue Tawn Estates S/D $2 June 7, 1996 GENERAL: 1. e e De The scope of this project includes the installation of a 1000 gallon septic tank and a leachfield trench to serve the three bedroom residence located on the referenced property. Construction shall be in accordance with the approved site plan and design drawings, Municipal permit with any special provisions or conditions, and all applicable State and Municipal Wastewater Disposal Regulations. The contractor shall be responsible for obtaining any necessary underground utility locates. Unless specifically agreed otherwise, the property owner shall be responsible for final grading areas subsequently depressed from soil settling. Contractors installing wastewater disposal systems must be certified by the Municipal Health Department for system installations. Owners installing their own systems must also receive prior approval from the Municipal Health Department. SEPTIC TANK INSTALLATION: A septic tank is to be constructed by a certified septic tank manufacturer. Construction shall include two 4" cleanouts for pumping access. The septic tank shall be sufficiently bedded to prevent settling or shifting of the tank. 3. Ail standpipes on the septic tank shall extend a minimum of 12 inches above final grade. 17034 NORTH EAGLE RIVER LOOP SUITE 204 EAGLE RIVER, ALASKA 99577 Page Two Lot 11, Block 1, June 7, 1996 Sue Tawn Estates S/D 92 Septic tanks installed with less than 4 ft. of cover shall be insulated. A foundation cleanout shall be installed one to four feet from the building foundation. In the line between the tank and the leachfield there shall be two adjacent cleanouts (unless an effluent pumping system exists within the septic tank). These cleanouts shall be located on undisturbed soil not more than 10 ft. from the tank. The first cleanout, in line, shall be to clean toward the leachfield. The second cleanout shall be to clean toward the septic tank. Final grading over the septic tank shall be such that a positive slope exists away from the septic tank. ABSORPTION TRENCH/DRAINFIELD INSTALLATION: Excavate the proposed trench to the dimensions shown on the design. The bottom of the excavation shall be within 2 inches of level. If the sidewalls of the excavation become smeared, they must be raked or scratched (ruffed-up) before gravel (sewer rock) placement. Once the gravel is installed, the distribution pipe is to be installed level with the perforations faced downward. Gravel is then to be placed over the distribution pipe to provide a minimum of 2 inches of cover over the pipe. Se A silt barrier must be installed between the final gravel layer and the native soil backfill. Ensure the silt barrier covers the entire gravel surface before placing backfill. Monitor tubes shall be of four (4) inch diameter, installed approximately in the locations shown on the design, and extend a minimum of 12 inches above final grade. The portion of the monitoring tube extending through the gravel shall be perforated from the bottom of the trench to the invert of the distribution pipe. This is equivalent to the effective depth of the gravel as noted on the design. Page Three Lot 11, Block 1, June 7, 1996 Sue Tawn Estates S/D 92 Backfill over the final gravel layer must not be less than twenty-four (24) inches. Insulation must be installed when the backfill depth is less than thirty-six (36) inches. The finish grade over the trench must be mounded to prevent the formation of a depression after settling. MINIMUM MATERIAL SPECIFICATIONS: me Any septic tank proposed for installation must be constructed by a Municipally approved septic tank manufacturer. The following pipe materials are approved for use in septic system installations in the Municipality of Anchorage: Type of PiDe Perforated Solid Cast Iron Yes Yes ASTM D3034 (PVC) Yes Yes ASTM F810 (HDPE) Yes No ASTM D2662 (ABS) Yes Yes Use of a type of pipe other than listed above must be approved by the inspecting engineer. 3. Insulation shall be at least 2" thick extruded direct burial polystyrene (Dow Chemical Company Styrofoam HI or equal). 4. Septic tank inlets and outlets shall be fitted with watertight couplings (Caulder, Fernco, or equal). A permeable nontoxic silt barrier (Typar 3401, Mirafi 140N, or equal) must be installed between the final leachfield gravel layer and the native soil backfill. 6. All leachfield gravel (sewer rock) shall be 0.5"-2.5" screened gravel with less than 3% passing the %200 sieve. When sand is being used as a filter material, its gradation specifications must conform to current M.O.A. or D.E.C. requirements. Page Four Lot 11, Block 1, June 7, 1996 Sue Tawn Estates S/D ~2 INSPECTIONS: Typically there will be a minimum of three (3) inspections required during the installation of the wastewater disposal system. These inspections will occur as follows: The first inspection must be conducted after the excavation of ditches, pits, trenches, or beds and before the installation of any gravel. A septic tank may be set in place, but may not be backfilled before this inspection. The second inspection must be conducted after the placement of the silt barrier, gravel, distribution lines, standpipes, cleanouts, and insulation, but before the placement of any other backfill. The final inspection is to occur upon final grading of the property. Often there will be more than these 3 inspections required. Especially with the installation of multiple trenches, sand filters, pressurized distribution systems, etc. Thus, the inspecting engineer is to be contacted at least 24 hours prior to the start of construction. If necessary, a pre-construction meeting will take place on-site. The inspecting engineer will not coordinate, direct or control in any way the contractors activities. The owner shall contract with the contractor to perform the work outlined in these specifications and plans and in accordance with the attached M.O.A. permit. There will be no contractual arrangement existing between the contractor and S & S Engineering. S & S Engineering shall be the owner's representative and will inspect the work as stated above to document the contractors activities. Final acceptance of the contractors work rests with the owner and the M.O.A. Page Five Lot 11, Block 1, Sue Tawn Estates June 7, 1996 S/D #2 S & S Engineering shall have no liability to the owner or to others for acts or omissions of the contractor or any other persons performing work on this project or the failure of the contractor to carry out the work in accordance with these construction documents. S & S Engineering's inspecting engineer will not be responsible for the construction means, methods, techniques, sequence, procedures or the safety precautions incident to this project. CONTRACTOR/INSTALLER MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 051-501~33 Parcel I.D. # 1. GENERAL INFORMATION Complete'legal description CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING '" :"'' ' HAA# Lot' 11; Block ~; Sue Tawn Estates #2 Location (site address or directions) Property owner Mailing address Lending agency Mailin. g address. 19030 Melissa Lane Chugiak~ AK Jody & Eileen Maus P.O. Box 672235 Chuqiak, Day phone AK 99567 Day phone 688-6801 Agent Address · .Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 3 TYPE OF WATER SUPPLY: Individual well XX NOTE: Community well Public water If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: NOTE: Individual on-site xx Holding tank Community on-site Public sewer If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-O25(Rav. l/91) Front MOA#21 STATEMEI r OF INSPECTION BY ENGINEER As certifiec~ by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the ~ of this inspection. Name o! I-irm Address / Enginee~ssignature ~__/ ~~ Date /o~ Alaska Waf~ '& Wastewater Consultants, Inc, Shall be PAID $ or prior to, closing for the . Engineering Se~ices Provide, DHHS SIGNATURE ~'/ A?proved for "/" /-J /~ F_ ~ bedrooms. Disapproved. Conditional approval for bedrooms, with thee following stipulations: Additional Comments The Municipality of Anchorage Department of'Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in orderto satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. Municipality of Anchorage OCT 1 DEPARTMENT OF HEALTH & HUMAN SERVICE~(-~e^L~ Environmental Services Division E~Vt~.QNMENI'ALSERV{CES 825 L Street, Room 502 * Anchorage, Alaska 99501 · (907) 343-4744 Health Authority Approval Checklist Legal Description: SUE TAWN ESTATES #2; LOT 11, BLOCK 1, A. WELL DATA Well type PRIVATE Log present (Y/N) Total depth 230' Sanitary seal (Y/N) Date of test Static water level Well production 18 WATER SAMPLE RESULTS: Coliform '~ Date of sample: ln/11/~¢) B. SEPTIC/HOLDING TANK DATA Date installed 6/29./96 Tank size Foundation cleanout (Y/N) YES Date of Pumping 7/16/99 C. ABSORPTION FIELD DATA Date installed 6/29./96 Length 52' Width 2.5' Effective absorption area 416 SQ,FT, Date of adequacy test 6/29/99 Pamel I.D.: 051-501-33 If A, B, or C, attach ADEC letter. ADEC water system number YES Date completed 7/2/96 Cased to 230' Casing height (above ground) YES Wires properly protected (WN) FROM WELL LOG AT INSPECTION 7/2/96 6/29/99 58' 162~ .g.p.m. N/A 2'+ YES 8,74. 4- g.p.m. Nitrate ~, 0'?':> Other bacteria '~" Collected by: A,W.W,C,, INC, ln[3n Number of Compartments 2 Cleanouts (Y/N).YES Depression (Y/N) NO High water alarm (Y/N) N/A Pumper JR'S PUMPING Soil rating (g.p.d./ft2 or ft~/bdrm) 1.2 System type TRENCH Gravel thickness below pipe 6.5' Total depth 10'-10.5' Monitoring Tube present (Y/N) YE,.%_ Depression over field (Y/N) NO Results (Pass/Fail) PASS For 3 bedrooms Fluid depth in absorption field before test (in.); Fluid depth 16.25" (ins) Minutes later: Peroxide treatment (past 12 months) (Y/N) 72-026 (Rev. 3/96)* 14-.5" Immediately after874 gal. water added (in.): 22.75" 60 Absorption rate = 450+ g.p.d. NONE KNOWN If yes, give date - D. LIFT STATION S~~. . Date installed Manhole/Access (Y/N) ~" v I at* "Pump off" level at* High water~ *Datum c_ cx , me d E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer/septic service line 100'+ 100'+ N/A 25'+ On adjacent lots 100'+ On adjacent lots 100'+ Public sewer manhole/cleanout Lift station N/A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Foundation D'+ Property line ~'+ Absorption field Water main/service line 10'+ Sudace water/drainage 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: Property line 1 o'+ Building foundation 10' Surface water 1 nn'4- N/A 5'+ Wells on adjacent lots Water main/service line Driveway, parking/vehicle storage area 100'+ 10'+ 10'+ Curtain drain NONE' F. ENGINEER'S CERTIFICATIO.~¢ I certifythatlh~, inconforrnan~ewith~ ~A~: Wells on adjacent lots inspections a ,s in effect on this date. GARNESS 100'.+ HAA Fee $. ,--"~ ~ · Date of Payment Receipt Number 72-026 (Rev. 3/96)* '-.'¢ '--?.? Waiver Fee $ Date of Payment Receipt Number Z m (DECK) (HSE) S i47.9 O/~oo '~ 0 230.$7' (PROP) 230.40 (REC) (BASIS) 893.10 (REC) 893.00 (MEAS) Z OCT'14-gg lg:53 FROM'CTE ENVIRONMENTAL 5615301 T'~35 P.01/02 F-565 CT&E Environmental Services Inc. Laboratory Division 200 W. Potter Drive Ancl~ora~e, AK 9B518 Tel: (907) 562-2343 Fax: (907) 661-5301 CT&E Ref. ~' Chent Name: Pro~ec~ Nama: Client Sample ID; Matrix; PwSID 99.5594-1 AK Water & Was[ewater Cons. n/a Lot 11 B1 Sue Tawn Est ~ Drinkin9 Waist nla Client PO~: n/a Prinma Date/rime: 10/14/09 13::30 Collected Data/T~me: 10/11/99 10:00 Received Date/rime; 10/12J99 11.55 Technical Director: Sample Remarks: Parameter Results PQL Units Total Coliform (MF) O co!/100 N~trate 2 03 0.5 mg/L Allowable Prep analys~s Method Limits Date Dare Init SM9222B 10/12/99 KAP EPA 300 10.8 10/12/99 SCL 0ct-14-99 10:17 CT&E .Anchorage/Micro 907 561-S301 P.02 CT&E Environmental Services Inc. Laboratory Division 200 W. Potter Drive Drinking Water Analysis Report for Total Coliform Bacteria ,.ohoraan. Tek (907) 562-2343 READ I/VSTRf'CTIONS ON REVERSE SIDE BEFORE COLLECTING SAMP£E Fax: (907) 561-5301 MUST BE COMPLETED BY WATER SUPPLIER TO BE COMPLETED BY I.ABOR,\ fOl(h' 0 PUBLIC WATER SYSTEM I,D. # '~ PRIVATE WATER SYSTEM O Send Results [] Send Invoice o~1 D~ RD. "-- a~ut,,~,-, ..... ,_, aul'rE 2B Send Results [] Send Inuoice Month Day Year SAMPLE TYPE: ~:~ Routine n Treated Water a Repeat Sample (for routine sample ~ Untreated Water with lab ret'. no. ) O Special Purpose Time Collected SAMPLE LOCATION Collected By Analysis shows this Water SAMPLE lo be: Satisfactory UnsatisPactory Sample over 30 hours old, results may be unreliable [] Sample too long in transit; sample should not be over 48 hours old at examination. to indicate reliable results. Please send new sample via special delivery mail. . Time Received Analysis Began ~xnalytlcal Methed: ~- Membrane Filter [] MMO-MUG . *-. t,~,~, tar colonie_s/100 ~nl. suit* Analyst 995594 Date: Time: Client notified o f~msaOs,r,a~ results: Phoned Spoke with Date: Time: . BACTERIOLOGICAL WATER ANALYSIS RECORD MMO. MUG Reault: Total Coliform E. Coil Membrane Filter: Direct Count C~ Colonies/100 mi Verification: LTB BGB COLIFIRM. Fecal Coliform Confirmation Final Membrane Filter Results Reported By Time _ Collform/l O0 mi lO/~'''~ hrs Faxed i~~ Member of tho SOS Group (Socidt6 G0ndrale de Surveillance) ENVfRONMENTAL FACILITIES IN ALASKa, CALIEORNIA, FLORIDA, ILLINOIS, MARYLAND, MICHIGAN, MISSOURI, NEW JERSEY, OHIO, WEST VIRGINIA MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D.# 05' ~ ~ 5'~°/-3 1. GENERAL INFORMATION Complete legal description HAA # /~/~4 q6~-¢23 Lot 11; Block 1; S~e Tarn Estates ~2 Location (site address or directions) NHN Melissa Lane chugiak, AK Property owner Mailing address ' Jod¥ & Eileen Maus P.O. Box 672235 Chugiak, 'Lending agency '. Mailing address Day phone AK 99567 694-2979 Day phone Agent ~ddress Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 3 TYPE OF WATER SUPPLY: Individual well xxx Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. ~x TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72q)25 [Rev* 1/91) Front MOA ~21 5. STATEMENT OF INSPECTION BY ENGINEER. As certified .by my seal affixed hereto and as of the validation date shown below, I verify that my .invest gat on of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and reg~lla'~i~s in effect an the date of this inspection. S & S ENGINEERING Name of Firm Address Eagle River, Alaska 99577 Engineer's signature r - Phone __Date DHHS SIGNATURE '? Approved for J~ Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments __Date The Mur~i~ipA!ity of AnChorage Department of Health and Human Servic~ (DHHS) issues Health Authority Appi'oval Certificat¢~':~ased only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this a s a courtesy to purchasem of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division 8~5 L Street, Room 50~ · Anchorage, Alaska 9950'1 · (907) 843 Health Authority Approval Checklist Legal Description: A. WELL DATA Well type ~ i,~ ~¢1'~''~ Log present ~)N) Total depth Sanitary seal~YN) If A, B, or C, attach ADEC letter. ADEC water .system number Date completed Cased to Z ;Ao I '7 - 2. --* -t f- Casing height (above ground) ~Z Wires properly protected ~,N) Date of test Static water level Well production FROM WELL LOG '7 *' z .- g.p.m. AT INSPECTION g.p.m. WATER SAMPLE RESULTS: Coliform Date of sample: B, [~T~HOLDING TANK DATA Date installed ~ ~ Zq -'t/, Tank size Foundation cleanout Date of Pumping r,,~ ~J Nitrate I. (~, Other bacteria Collected by: ~ ,~ ~ ~¢G~r~d(g Jo oo Number of Compartments __ Depression (Y/~) Pumper '7_. Cleanouts ~N)_ High water alarm (Y/['~ C. ABSORPTION FIELD DATA Date installed G - 2'1-q.~ Soil rating ~or fF/bdrm) J , '~.. System type Length ~'Zt Width Z..~ I Gravel thickness below pipe ~, · 5~ Totai'depth Effective absorption area H'l~.. ~ Monitoring Tube present ~N) '~/E5 Depression over field (Y/~ Date of adequacy test ~ L~C,J Results (Pass/Fail). "' For '~:~ bedrooms Fluid depth in absorption field before test (in.); 1~ Immediately after ~gal. water added (in.): Fluid depth '-'~- (ins) Minutes later: '"--- Absorption rate = .g.p.d. Peroxide treatment (past 12 months) (Y/N) ~ If yes, give date 72-026 (Rev. 3/96)* LIFT STATION Date installed ~ Manhole/Access (Y/N) ~....~a.~wF~n' level at* High wa e~ ~ *Datum C~ted "Pump off" level at* E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: --'~'.9'~holding tank on lot Absorption field on lot Public sewer main Sewer/septic service line On adjacent lots On adjacent lots Public sewer manhole/cleanout Lift station SEPARATION DISTANCES FROM~HOLDINGTANK ON LOTTO: Foundation I't'o~ Property line ~, ~ Absorption field Water ma n/serv ce line. I C~ k.t- Surface water/drainage i o¢,lJ~ Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: Property line Surface water Curtain drain Building foundation. ~,51 -t- Water main/service line Driveway, parking/vehicle storage area Wells on adjacent lots 1 o~ ~ ~- F. ENGINEER'S CERTIFICATION I certify that I have determined thru field inspections and review of Municipal records in conformance with MOA HAA g~lidelines ip effect on this date. Signature '~.~Z. ~ d'. Engineer's Name Date HAP, Fee $ ~;~) Date of Payment Receipt Number '~--/~ ,.~ ~ ~ ~'~-~ 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number